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Socioeconomic Status of Women with Diabetes --- United States, 2000

Persons whose socioeconomic status is low have poorer health than other persons
(1,2) and are less likely to have adequate access to care or to receive high-quality clinical and prevention care services
(3). In the United States, diabetes is a
potentially debilitating disease that is increasing in prevalence
(4); however, little is known about the socioeconomic status of
persons with diabetes (5--7). Women account for approximately 52% of all persons aged
>20 years with diabetes (4).
To assess the socioeconomic status of women with diabetes, CDC analyzed data from the Behavioral Risk Factor Surveillance
System (BRFSS), which indicated that the socioeconomic status of women with diabetes in 2000 was markedly lower than that
of women without diabetes. Efforts should be focused to understand the impact of socioeconomic conditions on the health
and quality of care of women with diabetes.

BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. population aged
>18 years. In 2000, the median state-specific response rate was 48.9% (range: 28.8%--71.8%) (CDC, unpublished data, 2001).
Persons with diabetes were identified if they answered "yes" to the question, "Have you ever been told by a doctor that you
have diabetes?" Women who answered "no" and those who had been told they had diabetes only during pregnancy were
considered not to have diabetes. Data on level of education and annual household income were used to assess socioeconomic
status; marital status, size of household, and employment status were used as indicators of living arrangements; and household
size was derived by adding the number of adults and number of children aged
<17 years. A woman was classified as having
low socioeconomic status if she did not complete high school or resided in a household with an annual income of <$25,000.

State-specific data were aggregated and weighted to reflect age, sex, and racial/ethnic distribution, and chi-square tests
were used to test all univariate associations. Because many persons aged 18--24 years have not completed their
education, socioeconomic status was evaluated only for women aged
>25 years. Multivariate logistic regression analysis was used
to examine the relation between having diabetes and not completing high school or living in a low-income household,
with control made for age, race/ethnicity, and living arrangements. The models then were used to calculate adjusted
percentages using the distributions of female respondents aged
>25 years in the total population. All analyses were conducted using
SASv8 software with SUDAAN to estimate standard errors.

Of the 109,680 women who participated in the 2000 BRFSS survey, 6,835 (6.3%) had been told by a doctor that they
had diabetes (mean age at diagnosis: 48.8 years). Women with diabetes were more likely than women without diabetes to be
aged >45 years; nonwhite; divorced, separated, or widowed; living alone; retired; or unable to work (Table 1).

Among women aged >25 years, the percentage with diabetes who had not completed high school (27.7%; 95%
confidence interval [CI]=25.7%--29.7%) was more than twice that of women without diabetes who had not completed high
school (12.2%; 95% CI=11.8%--12.6%) (Table 2). Among women with diabetes, 20.5% (95% CI=18.0%--25.3%) of those
aged 25--44 years had not completed high school, compared with 34.3% (95% CI=31.4%--37.2%) of those aged
>65 years. Among women without diabetes, 9.8% (95% CI=9.2%--10.3%) of those aged 25--44 years had not completed high
school, compared with 20.5% (95% CI=19.5%--21.5%) of those aged
>65 years. After multivariate adjustment, a low level
of formal education remained significantly more common among women with diabetes than among those without diabetes.

Overall, women with diabetes (40.4% [95%CI=38.1%--42.6%]) were approximately twice as likely as women
without diabetes (22% [95% CI=21.5%--22.5%]) to have an annual household income <$25,000. Among women with diabetes,
the percentages with incomes <$25,000 were highest for women aged
>65 years (47.8% [95% CI=44.4%--51.1%]) and
those aged <44 years (41.3% [95% CI=35.4%--47.2%]) and lowest (33% [95% CI=29.5%--36.6%) for women aged 45--64
years (Table 2). In each age group, percentages were lower for women without diabetes (32.9%, 19.7%, and 18.6%,
respectively). After multivariate adjustment, the difference between women with and without diabetes remained significant.

Editorial Note:

The findings in this report indicate that the socioeconomic status of women with diabetes is lower than
that of women without diabetes and confirm the findings of the 1989 National Health Interview Survey (NHIS)
(5). In 2000, at least one in four women with diabetes aged
>25 years had a low level of formal education, and 40% lived in
low-income households. Women with diabetes were more likely to have a low socioeconomic status independent of living
arrangements (i.e., marital status, size of household, and employment status). Attaining a higher educational level might influence
decision-making, and persons with a higher income might have better access to health care, higher living standards, and other
material benefits that have a positive impact on health. Although socioeconomic status might be influenced adversely by factors
related to having diabetes (e.g., being unemployed or retiring early), most women with diabetes in this survey were diagnosed
long after they had completed their education. BRFSS estimates suggest that the low socio-economic status of many women
with diabetes might compromise their ability to benefit from treatments that might reduce their risks for complications
and premature death. Programs designed to meet the needs of women with diabetes should take socioeconomic status
into account to assure that women benefit from the interventions. Performance should be carefully evaluated to assess
program effectiveness and identify areas for improvement.

The findings in this report are subject to at least three limitations. First, the low median response rate suggests the
potential for participation bias. Second, all data were self-reported and might be subject to recall bias. Finally, the level of
low socioeconomic status (i.e., household income <$25,000) among women with diabetes might be under-estimated because
21% of women with diabetes declined to state their income; these nonrespondents were more likely to be elderly,
Hispanic, widowed, retired, or not to have completed high school (i.e., to belong to groups that are frequently low income).

CDC has initiated activities that focus on the needs of women with diabetes. CDC's
"Diabetes and Women's Health Across the Life Stages: A Public Health
Perspective" analyzes the epidemiologic, social, and environmental dimensions of women
and diabetes and discusses public health implications
(8). CDC, the American Diabetes Association, the American Public
Health Association, and the Association of State and Territorial Health Officials are developing a National Public Health Action
Plan for Diabetes and Women. CDC is sponsoring Translating Research into Action for Diabetes (TRIAD), a 5-year
prospective study of the quality of diabetes care, costs, and outcomes in managed-care settings that will examine the effects
of socioeconomic status on health and quality of care. Finally, CDC is encouraging increased focus on women with
diabetes through the National Diabetes Education Program, a collaborative effort with the National Institutes of Health to
promote early diagnosis and improvement of the treatment and outcomes for persons with diabetes (available at
http://www.cdc.gov/diabetes/projects/ndeps.htm); Racial and Ethnic Approaches to Community Health (REACH) 2010, a program aimed
at eliminating disparities in the health status of ethnic minorities (available at
http://www.cdc.gov/reach2010), and
state-based diabetes control programs.

The low socioeconomic status of many women with diabetes poses challenges to public health practitioners. As
the prevalence of diabetes continues to increase, continued and creative efforts will be needed to gain greater understanding
of how socioeconomic status affects the health of women with diabetes.

Acknowledgement

This report is based on data contributed by state BRFSS coordinators.

References

Adler NE, Ostrove JM. Socioeconomic status and health: what we know and what we don't. Ann NY Acad Sci 1999;896:3--15.

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